Month: August 2017

In the fight against Neglected Tropical Diseases (NTDs), it has become obvious that learning from other countries’ successes will help many others to control and eliminate these diseases. This is how the China-Africa meeting and collaboration came about in 2012.

Whilst on a visit to the Liverpool School of Tropical Medicine, we caught up with Prof. Louis-Albert Tchuem Tchuenté regarding the China-Africa Meeting on Schistosomiasis Elimination and Training Course on Malacology, organised in Cameroon from the 24 – 28 October 2016.

Prof. Louis-Albert Tchuem-Tchuenté is an NTD Ambassador for Liverpool School of Tropical Medicine. He also heads the Centre for Schistosomiasis & Parasitology in Cameroon and is a professor of parasitology. He lectures at the University of Yaoundé I and is Country Director for the COUNTDOWN project in Cameroon. His expertise in Schistosomiasis and Soil-Transmitted Helminthiasis spans over 30 years. He is Cameroon’s National Coordinator for the control of Schistosomiasis and Intestinal Worms.

Discussions with Prof. Louis-Albert revealed that this China-Africa meeting started a long time ago. Given that China has a vast amount of experience in Schisto control and has successfully eliminated Schisto in many of their provinces; many African countries still struggling with schisto can learn from the Chinese experience. Very few areas have Schisto in China and Schisto has been eliminated as a public health problem there. The highest prevalence is probably 1-2 percent and the plan now is to interrupt the transmission everywhere.

According to Prof. Louis-Albert, China invested a lot on their elimination agenda including treatment, environmental modification and snail control. Most of the schistosomiasis cases in China are zoonotic because they have a lot of animals who act as reservoir hosts. That is why they have invested a lot of money to modify the environment so that the animals do not maintain the parasite life-cycle.

One of the highest components of this is the snail control. Schistosomiasis has two main hosts: vertebrate hosts (including human beings and animals) and the snails. In the transmission, you have both factors that make this happen. The snails are in the water and if you don’t change the environment, the snails remain present. Even if you reduce the transmission, then at some stage it just needs one person who is infected to defecate or urinate into the environment, to rebuild the transmission cycle. That is why it is very important to control the snails. The Chinese have done so successfully and have vast experience in snail control.

Based on this, it became important for African countries to benefit from the Chinese experience. That is why the World Health Organisation(WHO), together with the Chinese government, decided to have this China-Africa cooperation, for the elimination of schistosomiasis in Africa.

This began at the governmental level between China, WHO and the governments in Africa. The agenda was further discussed at the China-Health Ministerial Forum that reviews valuable health development issues. During the 2013 Minister’s Forum held in Beijing, an agreement was reached on this partnership and the initiative approved. This move was necessary to progress granted things take time at the government level. That is why the China team, WHO and African governments decided to start an institutional-based cooperation. This initiative was developed to sustain a China – Africa Cooperation for Schistosomiasis Elimination.

China has several provinces that are endemic for schistosomiasis and it was important to link these provinces to different African countries depending on the relationship they have. That is why in the first phase, ten countries were selected in Africa and were linked with different provinces in China.

The first meeting to set-up the institution-based cooperation was launched in 2015, in Malawi. The meeting launched the initiative and the memorandum of understanding between the partners. The memorandum was signed between different African institutions and Chinese institutions for research. The meeting in Cameroon was the second meeting and it was focused on snail and malacology training. Another component of the training was using mollusciciding to control the snails. The Chinese team and ten countries participated in the meeting in Cameroon.

The rationale for collaboration is clear as it fosters relationships between various actors and allows in-depth knowledge of what works in practice. This knowledge gets refined for better use through creating more cost-effective solutions which are sustainable in the long term for NTD control and elimination.

Control of mosquito and blackfly vectors of lymphatic filariasis and onchocerciasis is a well-known strategy to augment ongoing disease elimination interventions in sub-Saharan Africa. Similarly, although not strictly considered vectors, control of certain freshwater snails is again attracting considerable public health attention for targeted interventions against schistosomiasis, especially in stubborn hot-spot foci. As part of the annual meeting agenda for the International Society for Neglected Tropical Diseases (ISNTD), the importance of vector control for several NTDs, malaria and arboviruses was thrown into sharp focus at their annual ISNTD bites forum.

Each year the ISNTD has a one-day specific workshop to bring together scientists and public health practitioners to highlight the best of current cutting edge endeavours. Held on the 19th July 2017, at the Institute of Child Health, this meeting featured leading experts from UK institutions, NGOs and commercial partners to discuss vector-control solutions for NTDs and discuss global health actions. The meeting showcased the latest research on vector control as well as providing a practical platform and international network to cement implementation partnerships in vector control.

Key COUNTDOWN activities were featured to highlight our work on snail and blackfly control in South West Cameroon, and mosquito control in Ghana. The morning’s keynote speaker, Professor Gabriella Gibson from the University of Greenwich, set the scene and gave a broad overview of how knowledge of vector behaviour is key to improving control and surveillance for vector-borne NTDs. Examples from research showed how knowledge of tsetse and mosquito host-seeking behaviour led to the implementation of innovative control strategies, highlighting how vital the link between basic research and applied implementation really is. This is particularly important as development of insect traps and control methods are adapted to take advantage of weaknesses in their behaviour, leading to a better knock-down of fly populations.

Highlighting medical malacology and the importance of snail intermediate hosts, Professor Russell Stothard gave the opening talk in the first session; “Taking sensible steps in snail control in the crater lakes of Barombi Kotto and Mbo, Cameroon”. Although snails are technically reservoir hosts for schistosomiasis, they form an essential step in the environmental development of the schistosome to release copious amounts of highly motile cercariae, the infective form to people. Therefore, strategies which target this intermediate snail host can lead to effective environmental disease control and elimination. Sometimes, snail control approaches share much with vector control, especially when chemical molluscicides are used. Prof Stothard gave an overview of the current state of snail control, before revealing the recent epidemiological picture of schistosomiasis in the crater lakes of South West Cameroon. Information derived from mapping of water contact patterns at an individual level, ecological snail studies and community wide schistosomiasis prevalence studies, have helped build this detailed picture. This knowledge forms a solid foundation of evidence upon which snail control and interruption of schistosomiasis transmission can be built. See https://youtu.be/dZhx_u8h1yQ.

After talks from representatives of Merck, Natural History Museum, The London School of Tropical Medicine and Hygiene and Oxitec, Prof Stothard chaired the first panel discussion of the meeting. Key repeat themes of integration, and increased knowledge emerged from these discussions;

“The more we know about vectors, the more we know about parasites and host interactions, then weird and wonderful ways to control vectors arise” – Ailie Robinson, London School of Hygiene and Tropical Medicine.

“We need to collaborate, learn from each other and use a combination of approaches to beat NTDs” Theresa Maier, Merck

“To facilitate interdisciplinary working, COUNTDOWN is breaking down silos between different research areas.” Russell Stothard, COUNTDOWN.

These themes were further evident in the workshop on the MENTOR Initiative’s Integrated Vector Management Toolbox. In disaster and low resource areas, this workshop focused on effective, implementation ready strategies to control disease vectors in the most challenging of settings, led by Dr Richard Allan. Participants were encouraged to think outside the box, and to consider how a range of strategies could be tailored to particular settings and implemented at scale.

After lunch, there was a host of exciting talks on numerous topics, including a new drug target for tsetse control, improved performance management for NTD programs, Global Health Networks for Impact, and more fascinating discussion panels. It was also good to see other implementation research coming to the fore in the field of vector-borne NTDs, such as the digital monitoring platform Mango, presented by Greenmash; which can be easily tailored to suit specific project needs and has been used to make sure gender-disaggregated data is collected and readily available. This ties in with COUNTDOWN’s work on gender equity in NTD control.

Reflecting on the day from a COUNTDOWN perspective, it was a great opportunity to keep up to date on vector control and other NTD research at ISNTD Bites, and to make sure COUNTDOWN was a key part of the presentations and the discussions. It was particularly pleasing to note that interdisciplinary working and innovation emerged as some of the key themes in the meeting, areas where COUNTDOWN is actively providing evidence for vector borne-NTDs through implementation research on lymphatic filariasis, onchocerciasis and schistosomiasis. Participating in this meeting has ensured that COUNTDOWN keeps a firm finger on the pulse of NTD implementation research, and that the project has a loud voice at an international forum to advocate for our research and approaches.

[Irene is a Research Officer & Institutional Review Board Administrator at the Dodowa Health Research Centre. She is currently a researcher on the COUNTDOWN Project].

As researchers in the field, we are very concerned with ensuring positive community relations and conducting ethical research. But my experiences from the field show how challenging this can be. We are very careful to say “thank you” to study participants for taking part in our study and being respectful of their time. For qualitative research when a participant takes part in a focus group discussion or in-depth interview, we provide an incentive as a token of our appreciation or gratitude. In my organization, this has tended to come after we have conducted the method so participants do not feel pressure to participate. Yet, a dictionary definition of incentive is “a thing that motivates or encourages someone to do something”.

We were left with mixed feelings after the last COUNTDOWN research trip to the field. There was a sense of guilt and disappointment following various experiences with “incentives”. Throughout our data collection experiences, timing remained an important factor. We ensure we are in the field at times that suit the community. For example, in fishing and farming communities, we would arrive very early or much later to accommodate their activities. We also try to persuade community members to participate by telling them it will not take very long. However, despite our best efforts delays happen which can be very time consuming and frustrating. If we are undertaking in-depth interviews, we try to ensure we meet participants at the right time. But if we have made a few appointments and participants are not available at the agreed time, this can have an impact on the next appointment. If people have agreed to attend a focus group discussion and then turn up late, this can mean other people who were there on time must wait. In communities where people do not have sufficient food, asking people to wait longer can leave them feeling hungry and frustrated. This frustration can spill into the interview or focus group discussions.

I have noticed a pattern with participants. In the morning participants are often hungry and unhappy to wait. Sometimes we give them snacks. However, it has been agreed those snacks (incentives) be given at the end of the interview. We make sure they are hidden from their sight until the end of a discussion. Yet, once participants get the incentives they tell you “Oh we didn’t know you were going to give us anything, or we would not have pushed you and given our best”.

News of incentives does spread and there have been instances where an entire community troops to the venue of the meeting. They then tell us: “You should have told us you would give something!” One community surprised us when its members asked why survey participants were not given incentives. This is because the norm has always been not to give them incentives.

After one such community, a thought occurred to me: why do we not use advertisements for our recruitments? For example: “12 men/women needed for an FGD” and spell out what our study is about, including “incentives”. The advert could also add that admission of participants will be based on first come, first serve basis. Interestingly, advertisement is an ethically acceptable tool for recruiting research participants but we barely talk about it or consider it in the context of our research.

In my seven years at the research centre, it took my involvement on the COUNTDOWN project to realise this. Advertisement should however be done with the best interest of participants at heart, and in a clear, transparent and accountable manner. After all, they are volunteers and must not be forced or coerced in any way.